Discussion

4.3.1. The Association Between the Level of Internal Demands of Stress and
Demographics among Nursing Students in IDC

The perceived internal demands of stress levels among nursing students at IDC were
assessed using the Perceived Stress Scale (SHELDON COHEN). The sex assigned at birth
has a direct association, females' perceived higher levels of internal demands of stress
compared to males, which is consistent with previous research. Female students also reported
higher levels of stress compared to their male counterparts. These results coincide with several
studies stating that with the females reporting having a significantly higher perception of stress
(Graves et. al., 2018; Chang, 1995; Wangko, 1990). Recognizing the higher levels of perceived
stress among female nursing students suggests the need for targeted interventions and support
systems specifically tailored to address the unique stressors experienced by female students.
Providing resources and coping strategies that address gender-specific stressors can help
alleviate stress and promote overall well-being.

4.3.2. The Association Between the Level of External Demands of Stress and
Demographics among Nursing Students in IDC

The study examined the relationship between stress levels among nursing students at
IDC using the University Stress Scale (STALLMAN). The findings revealed that the year level
of the students had a moderate correlation with their perceived external stress levels.
Specifically, fourth-year students reported lower levels of stress compared to first and second-
year students. This could be attributed to the curriculum design, which gradually reduces the
workload as students progress through the nursing program. For instance, first-year students
had a higher number of units compared to fourth-year students. These results align with a
previous study, which also observed lower stress levels among senior nursing students. It's
important to note that individual and contextual factors can influence stress levels, and the
relationship between year level and stress may not be universally applicable to all nursing
students (Mohamed,2015). However, there is a consistent trend suggesting that senior students
generally experience lower levels of stress compared to their junior counterparts. To address
this, nursing schools can consider reviewing and adjusting the curriculum to distribute the
workload more evenly across different years. By reducing the course load or adjusting its
difficulty in earlier years, institutions may help alleviate stress levels among junior students.
Moreover, recognizing that junior students may face higher levels of stress, nursing schools can
provide targeted support and resources to assist them in coping with the demands of the
program. This can include offering stress management workshops, counseling services, study
skills training, and mentorship programs. Taking a proactive approach to address stress can
promote student well-being and improve retention rates. It's crucial to acknowledge that stress
levels can vary among individuals, and not all students will experience the same levels of stress
based solely on their year level. Therefore, institutions should adopt personalized approaches to
student support, considering the unique needs and circumstances of each student.

INTERNAL

When clustered independently to internal demand of stress, the correlation coefficient

shows that the protective behaviors namely; Positive Reinterpretation and Growth, Seeking
Emotional Support, Planning, Active Coping and Seeking Instrumental Social support are
negatively correlated in internal demand of stress which means that when these specific
protective behaviors initiated, the lesser they experience internal stress. These findings coincide
with the results of Lazarus and colleagues, stating that when a nursing student experiences
internal stress they tend to use a more positive perspective by seeking emotional support
through their families, friends or loved ones (Lazarus et al. 1984). This also showed a similar
result of Kweku Esia-Donkoh and Esia-Donkoh (2011) and Galvan and colleagues (2022), in
that positive interpretation and growth was noted to be one of the most used coping strategies
in which students handle stress by looking in a more positive perspective, gaining life lesson
and mature as individuals. Therefore, it is understandable why a negative correlation exists
between this coping strategy and stress because a positive outlook and interpretation of events
may make any situation seem less stressful. It is evidently stated by Galvan and colleagues that
Planning, Active Coping, Seeking Emotional and Instrumental Support belong to the most
used coping strategies to handle stress effectively. Thus, it is understandable that the more
nursing students used Planning as protective behavior the more efficiently they manage time to
avoid any stress as possible and strategies on how to deal with a stressful situation. In addition,
Active Coping allows nursing students to actively adapt the ways in dealing with stressful events
such as taking direct action and taking one step at a time to get rid of the problem this was
supported by Al Shloul (2019) where he defined active coping by means of taking action or
exerting efforts to remove or circumvent the stressor. Lastly, for Seeking Emotional and
Instrumental Social support these are protective behaviors that permit nursing students to
seek instrumental help from family members, friends and others, such as advice or information
for emotional support, empathy and understanding.

EXTERNAL

External Demands of stress protective behaviors namely; Alcohol/Substance use and

Suppression of Competing Activities are positively correlated only in External demand of
stress which means that when these protective behaviors are initiated by nursing students, they
perceive high external stress. They used substance/alcohol inorder to deal with a distressing
situation to relieve unpleasant emotions when they experience external stress. This result is
related to Guruprakash and colleagues states that stress is one of the major growing mental
problems among highly educated health students, and it should not be ignored as it can cause
many other health issues. The correlational analysis shows in this study that substance/alcohol
abuse is positively correlated to stress level. According to Lazarus et al. (1984), The stressors
are influenced by external demands including noise, overcrowding, major life changes, pressure
from school work or family and stress from assignments and workload and stress from taking
care of patients. The higher they are bothered by the external stress the more they suppress
themselves from competing in other activities in order to deal with a specific stressor, which
later makes them more stressed because of pending other activities that were undone.

Thus, Protective Behaviors initiated by the nursing students in both internal and external
demands of stress are Mental Disengagement, Focus on Venting Emotions, Denial, and
Behavioral Disengagement shows a positive correlation to the level of both internal and
external demands of stress in result increasing these protective behaviors when nursing
students perceived high internal and external demands of stress. They used passive coping not
to deal with the situation, this means nursing students are considered to be more stressed or
exposed to many stressors that they tend to neglect the situation rather than resolving it. This
evidence is supported by Galvan et al. (2022) Stated that Mental disengagement, focus on and
venting emotions, and behavioral disengagement was seen to be positively correlated to stress,
the more they use these coping strategies, the more stress they tend to be. It is said that Mental
disengagement was seen to be positively correlated to stress, in other words, the more mental
disengagement was used, the more stress they tend to be. In a study by Ingen et al. (2016) a
sample population from the Netherlands answered their survey with 57% of them making use of
mental disengagement by utilizing online coping strategies like online gaming, social network
site & online support groups after a stressful encounter. It appears from their data that doing
these activities more only worsen their stress levels. However, other literature addresses in the
field of work, mental disengagement helps an individual to temporarily detach from work to be
able to benefit workers well-being like relaxation, life satisfaction & absence of stress
(Sonnentag, 2012). Perhaps this indicates that mental disengagement can only be effective
under certain circumstances. Focus on and venting of emotions appear to have an adverse
effect on the nursing students stress levels. Karastoyanov and Kumanova (2013), assert that
people who usually use reactive emotion-focused coping strategies such as focus on and
venting of emotions, experience more stress. Nelson et al. (2001) reveals that in dealing stress
successfully, more women students use focus on and venting of emotion as the primary coping
style among students, increasing awareness of one’s emotional distress and a concomitant
tendency to ventilate or discharge those negative feelings to relieve stress. According to Al
Dubai, (2011) Denial is defined as an attempt to reject the reality of the stressful event, in other
words when this protective behavior is initiated the more they deny and neglect the situation.
According to Thuen & Bru (2004), behavioral disengagement coping style could lead to
problems gradually because of giving less effort to a particular work or action, for example
displaying less importance to schoolwork, could lead to academic failure and inappropriate
student behavior. Another literature by Jerome and Liss (2005) states that those people who do
not feel sensory stimulation may, most of the time, deny stressors around them and they tend to
disengage behaviorally and mentally to stressors. This may be the reason the stress is not well
managed.

DEFINITION OF TERMS

1. Positive Reinterpretation and Growth

- Positive reinterpretation and growth are processes of choosing positive emotions from
stimuli in the environment and applying them to perceptions and beliefs and also create
an outlook that translates into a new or better chosen reality. (Neuro-Psiquiatr, 2014)

- In this research, positive reinterpretation and growth was noted to be one of the most
used coping strategies in which students handle stress by looking in a more positive
perspective, gaining life lessons and mature as individuals. (Galvan, 2022)

2. Mental Disengagement
- Mental disengagement is the act of withdrawing from an attachment or relationship or,
more generally, from an unpleasant situation (American Psychological Association,
2022)

- In this research, mental disengagement is defined as means giving up or withdrawing

efforts to attain a goal(Al-Shloul, 2019) .

3. Focus on and Venting Emotion

- Venting emotion is defined as to express (a strong emotion, such as anger) in a forceful
and open way. (Merriam Webster)

- In this research, focus on and venting of emotion is used as an expression in expressing

emotions when under stress.

4. Use of instrumental social support

- Assistance provided to meet tangible needs is known as instrumental support, a type of
social support. Instrumental support is identified by actions that include help with
personal and medical care, transportation, and meal preparation (Schultz, 2022).

- In this research, the use of instrumental social support is defined as the support that is
provided from our friends, families and loved ones.

5. Active Coping
- Active coping is generally associated with more adaptive adjustment and characterized
by strategies such as problem-focused coping (Wood & Bhatnagar, 2015).

- In this research, active coping is defined by means of taking action or exerting efforts to
remove or circumvent the stressor (Al-Shloul, 2019) .

6. Denial
- Denial is defined as refusing to admit the truth or reality of something unpleasant
(Merriam Webster)

- In this research, Denial’ is defined as an attempt to reject the reality of stressful events
(Al-Shloul, 2019) .

7. Religious Coping
- Religious coping is religiously framed cognitive, emotional, or behavioral responses to
stress. It may serve many purposes, including achieving meaning in life, closeness to
God, hope, peace, connection to others, self-development, and personal restraint
(Pargament, 1997)

- In this research, religious coping is defined as to the use of cognitive-behavioral

techniques to manage stressful situations in light of one’s spirituality or religious beliefs
(Pargament, 1997)

8. Humor
- Humor is the quality of being funny (Collins- dictionary, 2022).

- In this research, Humor is something that makes a joke about the stressor (Al-Dubai et
al., 2011).

9. Restraints
- Restraints is a control over the expression of one's emotions or thoughts (Merriam-
webster, 2022)

- In this research, Restraint is waiting until an appropriate opportunity to act presents

itself, holding oneself back, and not acting prematurely (Esia-Donkoh et al., 2011).

10. Behavioral Disengagement

- Behavioral disengagement is a coping style reflecting the tendency of students to give in
or reduce their efforts in difficult situations (Thuen et al., 2004).

- In this research, Behavioral disengagement refers to reducing “one’s effort to deal with
the stressor, even giving up the attempt to attain goals with which the stressor is
interfering” (Carver et al., 1989).

11. Use of emotional social support

- Emotional social support is the offering of empathy, concern, affection, love, trust,
acceptance, intimacy, encouragement, or caring. It is the warmth and nurturance
provided by sources of social support ( Collins Dictionary, 2022)

- In this research, Emotional social support is seeking for emotional support, sympathy or
understanding ( Carver., 2013).

12. Substance use

- Substance use is excessive use of a drug (such as alcohol, narcotics, or cocaine) , use
of a drug without medical justification ( Merriam-Webster, 2022 )

- In this research , substance use refers to use of alcohol or drugs to relieve unpleasant
emotions ( Carver., 2013)

13. Suppression of competing activities

- The conscious intentional exclusion from consciousness of a thought or feeling
(Merriam-Webster, 2022).

- In this research, suppression of competing activities is putting aside other activities not
connected to the problem in order to better deal with it (Carver, 2013).

14. Acceptance
- The act of accepting something or someone , the fact of being accepted (Merriam-
Webster, 2022)

- In this research, Acceptance means accepting the stressful event ( Al Shloul., 2019).

15. Planning
- The act or process of making or carrying out plans ( Merriam-Webster, 2022)

- In this research, Planning consists of thinking about how to confront the stressor ( Al
Shloul, 2019)